©  The Ulster Medical Society, 2007.

Presidential Address 107

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ABSTRACT

Potentially life threatening diseases can mimic a groin hernia. We present an unusual case of diverticulitis with perforation and  a  resulting  abscess  presenting  as  a  strangulated inguinal  hernia.  The  features  demonstrated  were  not  due to  strangulation  of  the  contents  of  the  hernia  but  rather pus  tracking  into  the hernia sac from the peritoneal cavity. The  patient  underwent  sigmoid  resection  and  drainage  of retroperitoneal and pericolonic abscesses. Radiological and laboratory  studies  augment  in  reaching  a  diagnosis.  The differential diagnosis of inguinal swellings is discussed.

Key Words:  Diverticulitis,  diverticular  perforation, diverticular abscess, inguinal hernia

INTRODUCTION

The  association  of  complicated  inguinal  hernia  and diverticulitis  is  rare1. Diverticulitis can present as  left  iliac fossa  pain,  rectal  bleeding,  fistulas,  perforation,  bowel obstruction  and  abscesses.  Our  patient  presented  with  a diverticular  perforation  resulting  in  an  abscess  tracking into  the  inguinal  canal  and  clinically  masquerading  as  a strangulated inguinal hernia. The management warranted an exploratory laparotomy and drainage of pus.

CASE REPORT

An 86 year old woman presented to the emergency department with a long standing history of reducible left groin swelling which had become irreducible, painful and erythematous. She 

noted nausea, anorexia and increasing abdominal pain. She had no previous history of any surgery or trauma and was on warfarin for atrial fibrillation. 

On admission, she had a tachycardia (pulse 102 beats/min) and  a  temperature  of  37.5OC.  Blood  pressure  was  130/69 mmHg.  On  examination  the  abdomen  was  soft  with  a swelling in the left groin that was nonfluctuant, erythematous, indurated and tender (Fig 1). There was no peritonitis. Digital rectal  examination  revealed  tenderness  anteriorly.  Blood laboratory values were unremarkable with the exception of a raised CRP of 137 mg/l (normal <10 mg/l)and leukocytosis (13,000/mm3). No intra-abdominal free air was identified on an erect chest X-ray. CT scan (Fig 2) of the abdomen showed bilateral inguinal herniae, with marked inflammatory changes with stranding of the subcutaneous fat on the left side. The differential  diagnosis  included  an  irreducible  small  bowel hernia  without  obstruction  and  herniation  of  the  sigmoid colon with associated diverticular abscess. 

Case Report

Diverticular Abscess Presenting as a Strangulated Inguinal Hernia: Case Report and review of the literature.S Imran H Andrabi, Ashish Pitale*, Ahmed AS El-Hakeem

Accepted 22 December 2006 

Department of Surgery, Craigavon Area Hospital, 68 Lurgan Road, Portadown. BT63 5QQ. United Kingdom, and  *Department of Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast. BT12 6BA.

Correspondence to: Mr Andrabi, 73 Sicily Park, Finaghy, Belfast BT10 0AN. United Kingdom.

E: imranandrabi@gmail.comFig 1.  Erythematous and indurated left groin area 

Fig 2.  CT scan showing inflammatory changes with stranding of the subcutaneous fat in the left groin and a 

large bowel diverticulum

Ulster Med J 2007; 76 (2) 107-108

©  The Ulster Medical Society, 2007.

108 The Ulster Medical Journal

A  lower  midline  laparotomy  was  performed.  Findings showed  sigmoid  diverticulitis  complicated  by  perforation and  a  paracolonic  abscess.  The  abscess  tracked  along  the round  ligament  through  the  inguinal  canal  and  into  the subcutaneous  space  of  the  left  lower  quadrant,  and  was associated with a plug of indurated inflamed omentum into the  inguinal  canal. The  pus  was  drained  and  after  a  wash out,  a  standard  Hartmann’s  procedure  was  performed. The inguinal  hernia  was  not  repaired  at  this  stage. The  patient continued on IV antibiotics (cefuroxime and metronidazole). Pus cultures were positive for K. pneumonia and B. fragilis. The post-operative course was complicated with respiratory tract  infection  and  a  confusional  state.  Pathology  showed a  perforation  in  a  sigmoid  diverticulum  with  histological examination confirming diverticular disease with diverticulitis and peridiverticular abscess formation and a perforation. The patient  responded  to  antibiotic  treatment  along  with  other standard chest management and had a slow recovery.

DISCUSSION

A  wide  variety  of  pathological  processes  and  diseases present as atypical inguinal hernia. We present this unusual case of  diverticulitis with perforation. The  abscess  formed tracked along the round ligament through the inguinal canal and  presented  clinically  as  a  strangulated  inguinal  hernia. Appendicular abscesses2 and appendicitis3 have been reported on  the  right  side  in  the  hernial  sac.  The  presence  of  an appendix within an inguinal hernia is not uncommon and is labelled an Amyand hernia4. 

Enlarged  lymph  nodes,  lipomas  or  abscess  of  the  psoas muscle5 can present as an inguinal swelling. Patients with no evidence of bowel obstruction clinically and radiologically, presenting  with  a  painful  inguinal  swelling  have  a  risk  of significant  extra-abdominal  and  intra-abdominal  disease processes. An infected hip prostheses abscess6, a subcutaneous fungal abscess7, pancreatic pseudocyst8,  leaking abdominal aortic aneurysm9, and peritonitis10 can present as an atypical inguinal hernia. In females leiomyoma of the round ligament11, endometrial carcinoma12, ovarian cysts13 and Bartholins cysts14 are  reported.  In  males,  torsion  of  an  undescended  testis15, hydrocele and sarcoma of the spermatic cord16,17 can present as an inguinal swelling. Sarcoma18, lymphoma19, and metastatic carcinoma  from  ovary,  gastrointestinal  tract,  prostate  and mesothelium20 have been confused with the presentation of inguinal hernia. We could not find any reports of complicated diverticulitis to present  as a strangulated hernia in patients with pre-existing inguinal hernia.

CONCLUSION

We report a case of perforated sigmoid diverticular abscess, on physical examination and radiographic evidence thought to be a strangulated inguinal hernia. Careful history taking, physical  examination  and  a  CT  scan  of  the  abdomen  and pelvis  should  help  reach  a  diagnosis,  as  it  is  important  in planning the management especially in elderly patients with co-morbidities. Thus radiological evidence of incarceration, signs of bowel obstruction and local signs of inflammation should help direct  the differential  diagnosis. The proposed treatment remains surgery and drainage of pus and resection of the diseased bowel. The main conclusion is that an appearance of a tender red irreducible hernia may not always be due to 

strangulation of the contents but also due to inflammation of the hernia secondary  to  intra-abdominal pathology such as generalised peritonitis or abscess formation.

The authors have no conflict of interest.

REfERENCES

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